Waters Of Hobart Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobart, Indiana.
- Location
- 2901 W 37th Ave, Hobart, Indiana 46342
- CMS Provider Number
- 155251
- Inspections on file
- 25
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Waters Of Hobart Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Surveyors identified improper storage of chemical test kits above food items, multiple instances of unlabeled and undated opened food in various storage areas, and inaccurate completion of temperature and sanitation logs. These deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Surveyors found multiple deficiencies in environmental cleanliness and repair, including scratched chair rails, marred floors and walls, missing or taped toilet paper holders, dirty baseboards, stained over-bed tables, and uncontained personal care items in shared rooms. These issues were observed in both units and confirmed by the Maintenance Director, affecting several rooms occupied by residents.
Surveyors found that drugs and biologicals were not consistently labeled or securely stored, including topical medications left at a resident's bedside and loose pills and improperly labeled insulin pens in medication carts. Staff confirmed that some medications were left after refusals or brought in by residents, and the DON was informed of these issues.
Two residents with moderate cognitive impairment were found with medications at their bedside or left to self-administer without required physician orders or interdisciplinary assessments. In both cases, staff did not follow facility policy for self-administration of medications, which mandates proper assessment and documentation.
A resident with multiple medical conditions repeatedly refused doses of Eliquis, an anticoagulant, over several days. Despite facility policy requiring physician notification after two consecutive refusals, there was no documentation that the physician was informed. The DON confirmed that the physician should have been notified.
Two residents had inaccurate MDS assessments: one was documented as having no mobility or hearing impairment despite observed hemiplegia and significant hearing loss, and another was incorrectly coded as receiving insulin injections without any supporting orders or documentation. The MDS coordinator confirmed these errors and acknowledged not directly assessing one of the residents.
A resident with severe cognitive impairment and dependence on staff for ADLs was observed over several days with dirty, long fingernails and dry, scaly feet, with skin flakes accumulating on her bed sheet. The resident expressed a desire for shorter nails and lotion on her feet. Medical records indicated diabetes, heart failure, and a need for at-risk foot care, but there was no documentation of skin or nail care being provided or refused in the past month. The DON was informed of these findings and had no further information.
The facility did not ensure timely follow-up for a post-operative wound, failed to regularly assess and manage edema for a resident with vascular disease, and held insulin doses for a diabetic resident without physician orders. These deficiencies were identified through observations, record reviews, and staff interviews, revealing lapses in communication, documentation, and adherence to care plans.
A resident with diabetes and spinal cord infarction experienced ongoing pain and infection from ingrown toenails, repeatedly requesting podiatry care without follow-up from staff. Despite physician orders and care plan interventions for podiatry referral, there was no documentation that the resident was seen by the in-house podiatrist, and the resident was not included on the podiatry visit list.
Two residents with COPD and other conditions received oxygen therapy at flow rates inconsistent with physician orders, as staff set the oxygen concentrators either below or above the prescribed levels. The DON confirmed that the flow rates should have matched the orders, but repeated observations showed ongoing discrepancies.
A resident with multiple cardiac conditions was prescribed Metoprolol Tartrate with instructions to hold the medication based on specific heart rate and blood pressure parameters. Despite this, staff administered the medication without documenting the required vital signs, and the necessary monitoring was not performed or recorded, as confirmed by nursing leadership.
Two residents with significant medical conditions did not have complete or accurate documentation of infection monitoring in their medical records. On two occasions, the MAR indicated that infection monitoring was performed, but there was no supporting documentation to confirm whether signs or symptoms of infection were present or absent. The DON attributed these discrepancies to documentation errors by nursing staff.
An LPN failed to follow proper infection control procedures when cleaning a shared glucometer for a resident's blood sugar test. The LPN used a germicidal wipe but immediately dried the device with a tissue, rather than allowing the required contact time and air drying as specified by manufacturer guidelines and facility policy. Interviews confirmed staff were expected to follow these protocols, but the observed practice did not comply.
A resident with a history of stroke and diabetes did not receive proper pressure ulcer care as ordered. The facility failed to ensure the dressing was in place and zinc oxide was applied, as per physician's orders. Discrepancies were found between the treatment orders and the care provided, with continued use of medical grade honey instead of the updated treatment. The facility's policy for immediate transcription and initiation of treatment orders was not followed.
The facility failed to document the residual volume after checking the placement of feeding tubes for two residents, despite physician's orders and care plans requiring such documentation. Both residents had feeding tubes supplying significant nutrition and fluids, but the facility did not adhere to the required monitoring and documentation procedures.
A facility failed to communicate with a dialysis center regarding a resident's location when they did not return from an appointment. The resident, with end-stage renal disease and dementia, was dependent on staff and required scheduled dialysis. The facility did not verify the resident's whereabouts, and a Nurse's Progress Note incorrectly stated the resident was discharged against medical advice. Interviews revealed the resident was taken home by family after dialysis, and the dialysis center did not notify the facility, assuming the family would. The facility's policy required communication, which was not followed.
A facility failed to maintain accurate documentation for a resident, including missing records of a pacemaker and defibrillator, a canceled neurosurgery appointment, and pressure ulcer assessments. The Corporate Regional RN noted discrepancies in the records, with some information potentially documented on the wrong resident's record.
Staff failed to use correct PPE for residents under Enhanced Barrier Precautions (EBP). A CNA provided care to a resident with a feeding tube without proper PPE, believing EBP was not needed. Another instance involved staff initially using only gloves before applying gowns for a resident under EBP. Both residents' care plans required EBP due to feeding tubes, and the facility's policy mandated gowns and gloves for high-contact care.
The facility was found to have several environmental deficiencies, including discolored floor tiles, missing caulk, leaking toilets, and dried tube feeding on poles. Personal items were not contained in shared bathrooms, and a strong urine odor was present in one room. These issues were observed during an environmental tour of the West Unit.
Two residents were found with medications at their bedside without physician's orders or assessments for self-administration. One resident, cognitively intact, had hydrocortisone cream and an Albuterol inhaler, while another, with moderate cognitive impairment, had Iodosorb gel. The facility failed to conduct required assessments, leading to the deficiency.
The facility failed to provide adequate ADL assistance for two residents, who were observed with long, dirty fingernails and facial hair. One resident, dependent on staff for personal hygiene, had not received documented care since early July. Another resident expressed a desire for nail trimming, but staff focused on grooming only on shower days. Documentation practices were questioned as there was no recent record of nail trimming.
The facility failed to assess and monitor skin conditions for a resident with bruising, did not follow physician's orders for medication administration for another resident, and neglected to assess a resident's edema. These deficiencies were identified during a survey, highlighting lapses in care and documentation.
A resident with a history of stroke and other health issues was observed with thick, discolored toenails, indicating a fungal infection. Despite a Podiatrist's recommendation for Cyclopirex cream, no physician's order was found in the records. The resident's toenails worsened over time, and a Nurse Consultant confirmed the absence of the medication order.
A facility failed to ensure a splint was ordered and applied as recommended for a resident with a left hand contracture. The resident reported inconsistent application of the splint, which was supposed to be worn at night. Observations and interviews revealed the splint was not applied consistently, and there was no care plan or physician's order for its use. Staff were unclear about the splint's application schedule, and the Director of Rehab confirmed the lack of necessary documentation.
A resident with a suprapubic catheter was observed multiple times with the catheter bag and tubing touching the floor, contrary to infection control protocols. The resident had a history of diabetes, UTI, dementia, and other conditions, and was dependent on staff for personal hygiene. The facility failed to maintain proper catheter care as per their policy.
The facility failed to administer enteral feedings at the correct time and flow rate for two residents. One resident's feeding was off for hours despite orders for continuous feeding, while another's feeding was not administered as per the schedule, and equipment was not changed daily. Both residents had conditions requiring strict adherence to feeding orders, but the facility did not comply.
The facility failed to administer oxygen at the correct flow rate for three residents, as per physician orders. One resident was observed with oxygen set between 2.5 and 3 liters per minute, despite an order for 2 liters. Another resident consistently received 2.5 liters, contrary to the 2-liter order, with records showing a history of 3 liters. The third resident had no physician's order for oxygen, yet was observed with a 3-liter flow rate. Nurse Consultant confirmed the discrepancies.
The facility did not update the daily staffing sheet in a timely manner, as observed on a date when the sheet was three days old. The Administrator confirmed that the sheets should have been updated daily over the weekend.
Deficient Food Storage, Labeling, and Documentation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and preparation practices. In the walk-in cooler, three large boxes of UltraSnap Surface ATP test kits, which are chemical swab kits for testing surface cleanliness, were stored on top shelves above food items, contrary to the manufacturer's safety data sheet that specifies these products should be kept away from food and drink. Additionally, several food items in the walk-in cooler, walk-in freezer, reach-in cooler, and food prep area were found open, unlabeled, and undated, including bottles of tea and ranch dressing, packages of cheese, containers of jelly, bags of vegetables, and a bin of oats. An open can of shortening in the dry storage room was also found to be past its recommended disposal date. Further review of the facility's temperature and sanitation logs revealed that entries for refrigerator, freezer, and sanitizer solution temperatures were pre-filled for times that had not yet occurred, and the dishwasher temperature log was completed for a future date. The kitchen supervisor confirmed that all food items should have been labeled and dated when opened, and that temperature and sanitation checks should be recorded at the time the task is completed, not in advance. These findings had the potential to affect nearly all residents receiving food from the kitchen.
Environmental Cleanliness and Repair Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and well-repaired environment for residents in both the East and [NAME] Units. Specific deficiencies included scratched chair rails, marred floors and walls, missing or taped-up toilet paper holders, dirty baseboards, stained and dirty over-bed tables, and uncontained personal care items such as toothbrushes left on vanities in shared spaces. Additionally, a resident's wheelchair seat was found to be peeling and cracked. These issues were identified during an environmental tour with the Maintenance Director, who confirmed that the areas required cleaning and/or repair. The deficiencies affected multiple rooms, each occupied by one or two residents at the time of the survey.
Improper Labeling and Storage of Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not properly labeled or stored according to professional standards. On several occasions, topical medications such as clotrimazole, betamethasone diphenhydramine, and hydrogel were found left on a resident's nightstand, accessible to both the resident and their roommate. The resident, who had moderate cognitive impairment and required maximal assistance with activities of daily living, stated that staff left the medications in the room for wound care. The Director of Nursing was informed of these findings but did not provide further information at the time. Additionally, during inspections of two medication carts, surveyors found loose pills in medication cups, insulin pens labeled only with first names or initials and lacking administration instructions, and a probiotic bottle labeled with only initials. Staff interviews confirmed that some medications were left in the carts after resident refusals or were brought in by residents themselves. These observations demonstrated a failure to ensure that medications were consistently labeled and securely stored as required.
Failure to Ensure Proper Assessment and Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents had appropriate physician's orders and assessments for self-administration of medications. In one instance, two suppositories and a bottle of lubricating eye drops were found at a resident's bedside and overbed table, respectively. The resident's medical record showed no physician's order for the suppositories or for medications to be kept at the bedside, and a prior assessment indicated the resident did not wish to self-administer medications. The resident had moderate cognitive impairment and diagnoses including constipation and chronic pain. In another case, a cup containing a yellow liquid medication was observed on a different resident's bedside table, which the resident stated was left by a QMA for later consumption. The QMA confirmed the medication was Cholestyramine and stated she did not need to remain with the resident until it was taken. The resident's record showed no assessment or order for self-administration, and the resident had moderate cognitive impairment, was dependent in ADLs and transfers, and had diagnoses including Parkinson's Disease and anxiety. Facility policy required an interdisciplinary assessment and physician order for self-administration, which was not followed in these cases.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify a resident's physician of multiple medication refusals, specifically for Eliquis, an anticoagulant prescribed to the resident. The resident, who was cognitively intact and had diagnoses including hypertension, orthopedic aftercare, and peripheral vascular disease, expressed a dislike for taking Eliquis. Review of the Medication Administration Record (MAR) showed that the resident refused several doses of Eliquis over multiple days, including both morning and evening doses. Despite these repeated refusals, there was no documentation that the physician had been informed, as required by facility policy, which states that the physician should be notified if two consecutive doses are withheld or refused. The Director of Nursing confirmed during an interview that the physician should have been notified of the medication refusals. The deficiency was identified through record review and staff interviews.
Inaccurate MDS Assessments for Mobility, Hearing, and Insulin Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) comprehensive assessments were accurately completed for two residents. For one resident with a history of stroke, hemiplegia, and hearing loss, the MDS assessment inaccurately documented that the resident had no impairment in range of motion or functional limitation to upper and lower extremities, and that the resident could hear with minimal difficulty. Observations and interviews revealed that the resident was unable to move his left arm, had minimal movement in his left leg, and could only hear when spoken to loudly and in close proximity, even with a hearing aid. The MDS coordinator acknowledged that the assessment did not reflect the resident's actual mobility and hearing status and admitted to not assessing the resident directly. For another resident with diagnoses including metabolic encephalopathy, dementia, and bipolar disorder, the MDS assessment indicated that the resident received insulin injections. However, a review of the medical record showed no physician's orders or documentation of insulin administration during the relevant period. The MDS coordinator confirmed that this was a coding error and that the resident had not received insulin. These inaccuracies in the MDS assessments were identified through record review and staff interviews.
Failure to Provide Skin and Nail Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for a dependent resident, specifically regarding skin and nail care. Multiple observations over several days revealed that the resident's fingernails were dirty and long, and her feet were dry and scaly with skin flakes accumulating on her bed sheet. The resident, who had severe cognitive impairment and was dependent on staff for ADLs and transfers, expressed that she did not want her fingernails to be long and would like lotion applied to her feet. Her medical record included diagnoses of diabetes and heart failure, and a recent podiatry note documented extremely dry, scaly skin on more than 60% of her feet, indicating a need for at-risk foot care. Review of shower sheets from the previous 30 days showed no documentation that skin and nail care was completed or refused. The Director of Nursing was informed of these findings and did not provide additional information.
Failure to Provide Timely Treatment, Assessment, and Medication Administration
Penalty
Summary
The facility failed to provide necessary treatment and services for multiple residents as evidenced by several deficiencies. One resident with severe cognitive impairment and a recent pacemaker surgery had a dressing that was not fully adhering to the skin, with the incision sometimes visible. The resident was instructed to keep the dressing on until a follow-up appointment, which was delayed because the Medical Records Coordinator was unable to reach the physician's office for two weeks and did not escalate the issue to other staff. The Director of Nursing was unaware of the delay in scheduling the required post-operative appointment. Another resident with moderate cognitive impairment, Parkinson's Disease, and peripheral vascular disease exhibited visible swelling in the legs and feet during multiple observations and was not wearing the prescribed compression sleeves. The resident's record showed a lack of regular assessment of edema, despite physician orders and care plan interventions to monitor and report increased swelling. Additionally, a third resident with diabetes and an amputation had scheduled insulin doses held without physician orders or documented parameters, contrary to the care plan that required medications to be given as ordered. These findings were confirmed through record review and staff interviews.
Failure to Provide Timely Podiatry Care for Painful Ingrown Toenails
Penalty
Summary
A resident with diagnoses including type 2 diabetes and acute spinal cord infarction experienced ongoing pain and infection related to ingrown toenails. Despite multiple complaints to staff and documentation in the medical record indicating persistent symptoms such as swelling, pain, redness, and drainage from the toes, there was no evidence that the resident was seen by the in-house podiatrist. Physician orders and care plans specified the need for podiatry services as necessary, and nurse practitioner notes repeatedly referenced the need for podiatry referral and follow-up. Observations confirmed the resident had a bandage on his toe and expressed a desire to see the podiatrist, stating that staff had not followed up on his requests. The facility's social service designee confirmed that the resident was not on the list to be seen by the podiatrist during the last visit, and there was no documentation of a podiatry assessment or intervention for the resident's ongoing foot issues.
Failure to Administer Oxygen at Physician-Ordered Flow Rates
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered at the correct flow rates as ordered by physicians for two residents. For one resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), repeated observations showed that oxygen was administered via nasal cannula at 1.5 liters per minute, while the physician's order specified 2 liters per minute as needed to maintain oxygen saturation above 90 percent. The resident's medical record confirmed the order, and the DON acknowledged the flow rate should have been set at 2 liters. For another resident with COPD and chest pain, observations revealed that oxygen was administered at 4 liters per minute, while the current physician's order required continuous oxygen at 3 liters per minute via nasal cannula. The care plan also directed staff to administer oxygen per the physician's order. The DON confirmed that the flow rate should have been set at 3 liters. Both residents had moderate cognitive impairment and were observed multiple times receiving oxygen at incorrect flow rates, contrary to their physician's orders.
Failure to Monitor and Document Vital Signs for Cardiac Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring and documenting required blood pressure and heart rate parameters for a resident receiving Metoprolol Tartrate. The resident, who had diagnoses including ischemic heart disease, hypertensive heart disease with heart failure, and congestive heart failure, was prescribed Metoprolol with specific instructions to hold the medication if the heart rate was less than 60 or systolic blood pressure was greater than 110. Review of the Medication Administration Records for two months showed the medication was administered as ordered, but there was no documentation of the resident's heart rate or blood pressure at the time of administration. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that these parameters should have been documented and that a clarification order was needed for the blood pressure parameter.
Incomplete Documentation of Infection Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented regarding infection monitoring for two residents. For one resident with a history of stroke, hemiplegia, and severe cognitive impairment, the Medication Administration Record (MAR) indicated that monitoring for signs and symptoms of infection was required daily. However, on two specific dates, the MAR was marked as 'y' for infection monitoring, but there was no supporting documentation indicating the presence or absence of infection symptoms on those days. The Director of Nursing confirmed this was a documentation error, likely due to the nurse not understanding the correct documentation process. Similarly, another resident with diabetes, an acquired absence of the left foot, and moderate cognitive impairment also had a MAR requiring daily infection monitoring. On the same two dates, the MAR was marked as completed, but there was no additional documentation to support whether infection symptoms were present or absent. The Director of Nursing again identified this as a documentation error related to improper understanding of the documentation requirements.
Failure to Follow Proper Disinfection Protocol for Shared Glucometer
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during the cleaning of a shared glucometer. An LPN was observed preparing to check a resident's blood sugar level and stated she had already cleaned the glucometer but would clean it again. She used a germicidal wipe to clean the device and immediately dried it with a tissue before use. After testing the resident, the LPN repeated the cleaning process, again drying the glucometer immediately with a tissue before returning it to the medication cart. The LPN indicated she was unaware of any other cleaning method for the glucometer. Interviews with the Infection Preventionist and the Director of Nursing revealed that staff were expected to follow manufacturer guidelines, which require the disinfectant wipe to remain on the surface for a specified contact time (2 minutes for Sani Wipes) and to allow the device to air dry. The facility's policy also emphasized the importance of following contact/dwell time for effective disinfection. The observed practice of immediately drying the glucometer with a tissue did not comply with these guidelines, resulting in a failure to implement proper infection control procedures.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, leading to a deficiency. During an observation, it was noted that a pressure ulcer on the right side of a resident's sacral area was uncovered, and the dressing was not in place. The CNA and LPN involved were not informed about the missing dressing during their shift reports. The treatment for the wound was not completed as ordered, as zinc oxide was not applied during the treatment, despite being part of the physician's orders. The resident's medical history included stroke and diabetes mellitus, and they were dependent on all activities of daily living. The care plan indicated that the treatment should be completed as ordered, but discrepancies were found between the treatment orders and the actual care provided. The facility's policy required immediate transcription and initiation of treatment orders, which was not followed, as evidenced by the continued use of medical grade honey instead of the updated treatment ordered by the Wound Nurse Practitioner. The Corporate Regional RN acknowledged the discrepancies in treatment orders and the lack of documentation for the use of medical grade honey.
Failure to Document Feeding Tube Residuals
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with feeding tubes, specifically regarding the adherence to physician's orders for checking the placement of feeding tubes. For Resident B, who had a history of stroke and a severely impaired cognitive status, the facility did not document the residual volume after checking the feeding tube placement as required by the physician's order. The care plan and medication administration records (MARs) indicated that the feeding tube placement should be checked and documented before administering medications, formula, and flushing, but this was not done. Similarly, for Resident E, who had a severe protein deficiency and a moderately impaired cognitive status, the facility did not document the residual volume after checking the feeding tube placement. The physician's order and care plan required monitoring of the feeding tube for proper placement and gastric residual, but the MARs showed that the residual was not documented. During an interview, the Corporate Regional RN confirmed that the residual amounts were not documented. The facility's policy for enteral feedings required assessment of the feeding tube every eight hours, but this was not adhered to.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with a dialysis center regarding a resident's location when they did not return from a dialysis appointment. Resident C, who had diagnoses including end-stage renal disease with dialysis, stroke, and dementia, was dependent on staff for all activities of daily living. The resident's care plan required dialysis to be provided as scheduled, with sessions at a dialysis center on Monday, Wednesday, and Friday. On a Monday, the resident did not return from dialysis, and the facility did not check on their whereabouts. A Nurse's Progress Note incorrectly indicated that the resident was discharged against medical advice. Interviews revealed that the Assistant Director of Nursing discovered the resident had been admitted to the hospital on the same day they went for dialysis, but this information was not documented in the resident's record. LPN 4 was informed by an unknown source that the resident's Power of Attorney had transferred the resident to the hospital from the dialysis center. Dialysis Staff 1 stated that the resident's family took the resident home after treatment, and the dialysis center did not notify the facility, assuming the family would do so. The Corporate Regional RN acknowledged the need for improved documentation. The facility's hemodialysis policy required communication between the dialysis center and the facility, which was not adhered to in this case.
Deficient Documentation in Resident's Medical Record
Penalty
Summary
The facility failed to ensure accurate and thorough documentation in a resident's medical record, specifically concerning a physician consult appointment, cardiac assessment, and pressure ulcer assessment. The resident's record lacked documentation of a pacemaker and defibrillator, despite a nurse's admission assessment indicating their presence. There were no physician's orders for routine pacemaker monitoring, and subsequent progress notes did not mention these devices. An interview with the Corporate Regional RN revealed that the hospital paperwork did not document a heart monitor, pacemaker, or defibrillator, and the nurses who documented the information were no longer employed by the facility. Additionally, the facility failed to document the rescheduling of a canceled appointment with the Neurosurgery and Spine Institute. A nurse's progress note indicated the appointment was canceled due to transportation issues, but there was no further documentation of rescheduling. The Corporate Regional RN later discovered that the appointment had been canceled by the physician's office after a CT scan showed resolution of a hematoma. Furthermore, there was a lack of documentation regarding pressure ulcers, as a nutrition note indicated two open areas on the resident's skin, but these were not documented in the nurses' progress notes. The Corporate Regional RN confirmed that the dietitian was informed of the open areas but could not recall who provided the information.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to residents who were in Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) was seen providing care to a resident with a feeding tube without wearing the appropriate PPE, despite a sign indicating EBP was required. The CNA incorrectly believed the resident was no longer in EBP, attributing the oversight to a failure to remove the sign. The resident's care plan and physician's order both indicated that EBP was necessary due to the presence of a feeding tube and nebulizer treatments. In another instance, two staff members were observed preparing to provide care to a resident under EBP. Initially, they only donned gloves but later applied gowns and changed gloves after being interviewed about EBP. The resident's care plan and physician's order also required EBP due to a feeding tube. The facility's EBP policy, which was current, specified that gowns and gloves should be used during high-contact care activities for residents at risk, including those with feeding tubes. The Assistant Director of Nursing was informed of the EBP not being followed, but no further information was provided at that time.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, as observed during an environmental tour of the West Unit. In one room, the floor tile was discolored, the caulk around the toilet base was missing and discolored, and the toilet was leaking. Personal items such as toothbrushes and hairbrushes were left out on the bathroom counter in a shared bathroom. Another room had a strong urine odor, while two other rooms had dried tube feeding on the base of the tube feeding poles. Additionally, a bathroom floor was discolored, and a pink wash basin was not contained under the sink in a shared bathroom. These observations indicate a lack of proper maintenance and cleanliness in the facility.
Failure to Ensure Physician's Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents had physician's orders and assessments to self-administer medications. Resident 100 was observed with a tube of hydrocortisone cream and an Albuterol Sulfate inhaler on his over bed table without a physician's order or a self-administration assessment. The resident, who was cognitively intact, indicated that he kept the medications on his table for use as needed. The facility's records showed no orders for these medications or for self-administration, and the resident's family had brought the medications in without proper documentation or assessment. Similarly, Resident 2 was observed with an opened tube of Iodosorb gel on the dresser without a physician's order to keep it at the bedside. The resident, who had moderate cognitive impairment and multiple health issues, including hemiplegia and dementia, did not have a care plan for self-administration of the gel. The facility's policy required an interdisciplinary team assessment for self-administration, which was not conducted in these cases, leading to the deficiency.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the areas of nail care and facial hair removal. Resident 44 was observed multiple times with long, dirty fingernails and an accumulation of facial hair. Despite being dependent on staff for personal hygiene, as indicated in her care plan and MDS assessment, there was no documentation of her receiving a shower or bed bath since early July. The resident's medical history includes stroke, sepsis, dysphagia, type 2 diabetes, and chronic kidney disease, and she was identified as moderately impaired for daily decision-making. Similarly, Resident 22 was observed with long fingernails and unshaven, despite expressing a desire to have his nails trimmed. His care plan indicated an ADL self-care deficit, and he was also dependent on staff for personal hygiene. The last documented shower and shave for this resident was on July 1st. Interviews with staff revealed that nail trimming and shaving were typically performed on shower days, and there was no indication that additional grooming was provided upon request. The facility's documentation practices were questioned, as there was no recent record of nail trimming for Resident 22.
Deficiencies in Skin Assessment, Medication Administration, and Edema Monitoring
Penalty
Summary
The facility failed to properly assess and monitor skin conditions for Resident 100, who was observed with reddish/purple discolorations on his forearms. Despite the resident's cognitive intactness and partial assistance needs, there was no documentation of the bruising in the nursing progress notes or the Weekly Skin Check form. The facility's SWAT Program policy required such conditions to be documented and managed, but this was not followed, leading to a deficiency in care. Additionally, the facility did not administer medications according to physician's orders for Resident 44, who was moderately impaired in decision-making. The resident received Midodrine HCl despite having systolic blood pressure readings above the prescribed threshold on multiple occasions. Furthermore, Resident 250's swelling in the right hand and arm was not assessed by nursing staff, despite visible swelling and the resident's cognitive intactness. These failures in medication administration and assessment of edema contributed to the deficiencies identified by the surveyors.
Failure to Follow Podiatrist's Recommendations for Toenail Care
Penalty
Summary
The facility failed to follow a Podiatrist's recommendations for a resident with thick, painful, and fungal toenails. The resident, who was cognitively intact and had a history of stroke, hemiplegia, major depressive disorder, heart disease, and atrial flutter, was observed with long, thick, and yellow discolored toenails. The resident reported having seen a Podiatrist who diagnosed a fungal infection. The Podiatrist's exam notes from January 2024 indicated that all toenails were yellow, brown, crumbly, and thickened to 3 millimeters. The plan included debridement and a prescription for Cyclopirex cream to be applied daily for six months. However, there was no physician's order for the Cyclopirex cream found in the resident's records. A subsequent Podiatry Exam Note from April 2024 showed the toenails had thickened further to 4 millimeters, and the same debridement was performed. During an interview, a Nurse Consultant confirmed the absence of any additional information regarding the medication order from January 2024, indicating a lapse in following the Podiatrist's treatment plan for the resident's mycotic toenails.
Failure to Ensure Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a splint was ordered and consistently applied as recommended by therapy for a resident with limited range of motion (ROM) due to a left hand contracture. During observations, the resident was seen without the splint, which was supposed to be worn at night. The resident reported that staff did not put the splint on every night, and he had to request its application. The splint was observed on the nightstand, indicating it was not in use as required. Interviews with the resident confirmed that the splint was not applied the previous night. The resident's medical record revealed no care plan for the contracted left hand or for splint use, and there was no physician's order for the splint to be donned at night. Occupational therapy notes indicated the resident had previously tolerated the splint for several hours. Interviews with CNAs and the COTA revealed confusion about the splint's application schedule, with some staff believing the resident managed it himself. The Director of Rehab confirmed the absence of an order and care plan for the splint, despite the resident's need to wear it nightly.
Improper Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper care and maintenance of a suprapubic foley catheter for a resident, identified as Resident 22, who was observed with the catheter bag and tubing in contact with the floor on multiple occasions. These observations were made during random checks on two separate days, where the resident was seen sitting in a wheelchair with the catheter bag and tubing under the wheelchair, touching the floor. This practice is contrary to infection prevention and control techniques as outlined in the facility's catheter policy. Resident 22's medical record indicated a history of type 2 diabetes, urinary tract infection, dementia, high blood pressure, obstructive and reflux uropathy, and anxiety disorder. The resident was noted to be moderately impaired in daily decision-making and dependent on staff for personal hygiene, with an indwelling catheter in place. Despite these needs, the facility did not adhere to professional standards of practice for catheter care, as confirmed by a nurse consultant during an interview.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to ensure that enteral tube feedings were administered at the correct time and flow rate for two residents. For Resident 2, the enteral feeding was observed to be off for several hours despite physician orders indicating it should be infusing at 65 cc per hour for 20 hours daily. The resident, who had multiple diagnoses including dysphagia and was NPO, was observed without the feeding being administered as ordered. The care plan required feedings and flushes to be administered as ordered, but this was not adhered to, as confirmed by a nurse consultant. For Resident 251, the tube feeding was also not administered as per the physician's orders, which specified a rate of 70 ml per hour for 16 hours daily. Observations showed the feeding was off at various times, and the tube feeding equipment was not changed daily as required. The resident, who had a history of stroke and dysphagia, was cognitively intact and required nutritional support through a feeding tube. Despite the care plan's interventions to administer feedings as ordered, the facility did not comply, as acknowledged by a nurse consultant.
Oxygen Flow Rate Discrepancies for Three Residents
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate as ordered by the physician for three residents. Resident 13 was observed multiple times with oxygen set between 2.5 and 3 liters per minute, despite a physician's order for 2 liters to maintain an oxygen saturation of 90%. The resident's record indicated no care plan for oxygen therapy, and the resident was on hospice care. Nurse Consultant 2 confirmed that the oxygen should have been administered as per the physician's order. Resident 251 was consistently observed with oxygen set at 2.5 liters per minute, although the physician's order specified 2 liters per minute. The resident's record showed a history of receiving oxygen at 3 liters per minute, contrary to the current order. The Treatment Administration Record inaccurately documented oxygen administration at 2 liters per shift. Nurse Consultant 2 acknowledged the discrepancy in the oxygen flow rate. Resident 254 was observed with oxygen set at 3 liters per minute, but there were no physician's orders for oxygen administration in the record. The resident's care plan indicated oxygen therapy, but there was no specific plan related to oxygen use. A Daily Skilled Nursing Note mentioned the resident was on 2 liters of continuous oxygen, yet observations showed a higher flow rate. Nurse Consultant 2 noted the absence of an oxygen order and care plan for this resident.
Failure to Timely Post Daily Staffing Sheet
Penalty
Summary
The facility failed to post the daily staffing sheet in a timely manner, which is required to indicate the number of staff working and the facility census. On July 8, 2024, at 7:33 a.m., the staffing sheet displayed at the front desk in the main lobby was dated July 5, 2024. During an interview on July 11, 2024, at 2:58 p.m., the Administrator acknowledged that the staffing sheets should have been updated daily over the weekend.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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